An easier difficult choice - reducing agency staff spend in the NHS

This morning, the leadership cadre of the NHS assemble in Liverpool for their annual stocktake at the NHS Confederation conference. Over the past week some of the key players in the system have been busy setting the conference agenda.

David Bennett kicked off on Friday when he set out Monitor’s new and tighter cost-control regime for foundation trusts. On Sunday, Simon Stevens took to the Marr sofa to call for a ‘clampdown’ on temporary staff agencies that were ‘ripping off’ the NHS. Yesterday morning, Jeremy Hunt responded to his chief executive’s call with new measures to contain ‘extortionate’ agency costs: a cap on hourly rates, a cap on agency spend for struggling trusts and a ban on using agencies that have not been approved.  

In a context where difficult choices abound, agency spend is a relatively easy but nonetheless sensible place to start. Whilst there will be continued debate about whether £8bn of additional funding and £22bn of efficiencies are the right numbers for the next five years, few will disagree that spending more than £3.3bn on temporary staff is money poorly spent if more cost-effective alternatives are available.

The run up to the Francis inquiry and its aftermath rebalanced system priorities towards safer staffing at a pace which made it hard for some trusts to avoid significantly increased agency spend. With continuing challenges on nurse recruitment both nationally and locally, the NHS now needs to find more sustainable ways of providing safe care.

Restrictions on agency staffing will need to be applied with sensitivity if they are not to be honoured in the breach. In acute hospitals at least, the wriggle room for staffing at, or below, the margins of safe care is now rightly much reduced. Ward level transparency on a monthly basis leaves understaffed wards exposed and a more vigilant inspectorate is now on the case and ready to cry foul. It is a reality of busy wards that staff will call in sick and the bank won’t always be able to cover. If patients need care, agency staffing will need to remain a last resort, particularly in parts of the country where recruitment of permanent staff is a challenge.

Given this emphasis on safe staffing and addressing the challenges of the current financial year, acute hospitals (and the NHS more widely in primary, community and mental health) must now think hard, and fairly quickly, about how to provide care safely with more efficient use of staff.

In the future, that will mean different types of health professionals, different skill mixes, and a sustained and focused investment in improvement to support NHS professionals and managers in the hard task of streamlining and standardising care where it makes sense to do so.

It will mean learning from best employment practice in the NHS and elsewhere so that shift patterns are able to flex to the parenting and caring responsibilities of the workforce, making it as easy to be an employee as it is to be a temp.

Employers will also need to look hard at morale, work pressures and culture on the wards to ensure that the control over one’s own work offered by temporary employment is not preferable to the stability of full time shifts on Agenda for Change terms.

For now, as a leadership signal to a system facing five tough years (and more to come beyond that), tackling agency spend should be totemic – not just because it saves money, but because it points to a choice about how the NHS should face austerity. In his first major speech on the NHS David Cameron said ‘there is no choice between efficiency savings and quality of care’, ruling out simple trade-offs. High levels of agency staffing is a case in point and should ring alarm bells, whether you are a patient or taxpayer.  

Whilst agency nurses and medical locums will generally arrive for a shift highly skilled and well-motivated, some of the key ingredients of really good care may be absent – an appreciation of the strengths and weaknesses of the team they are joining, an understanding of the particular routines, informal workarounds and clinical processes of the ward, and a sense of allegiance to the work of the organisation and its patients. It takes time for good professionals to be inducted into a team and to learn to function safely and efficiently in a new environment. An itinerant and intermittent workforce makes mistakes, gaps or duplication more likely. In this context, safe and efficient care go hand-in-hand.

I'm delighted that the Health Foundation has given me the opportunity to lead a programme of work to explore workforce issues like these in greater depth. Over the next two years I'll be trying to develop a better understanding of what makes staff tick and, in light of that, how different blends of national and local policy can support staff in meeting the big challenges the NHS faces.

As delegates debate in Merseyside bars and breakfast meetings, there is likely to be support for measures which will clearly help in facing the financial and quality challenge. Conversation will then turn to the rest of the £22bn, where the task of driving further improvements to quality and efficiency will be harder. That the leaders of the NHS are continuing to send signals on both of these goals this week is a good thing. There is now much more work to be done on how the centre and the front line can work together to create the right conditions for squaring this circle.

Gavin is a Policy Associate at the Health Foundation, www.twitter.com/gavin_larner